Sinusitis: Medical and Surgical Management. R. Jonathan Lara, DO, FAOCO. Sonoran Ear Nose & Throat

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1 Sinusitis: Medical and Surgical Management R. Jonathan Lara, DO, FAOCO Sonoran Ear Nose & Throat 27 th Annual Southwestern Conference on Medicine April 26, 2018

2 What are sinuses? Air filled cavities of the head Maxillary, ethmoid, frontal, sphenoid sinus cavities

4 Why do we have sinuses? Provide mucus to upper airways/nose for: Lubrication Filter: Vehicle for trapping viruses, bacteria, foreign material for removal Humidify air inhaled Warm air inhaled Give characteristics to individual voices Lessen skull weight Involved with smelling function

5 Sinusitis Sinus + Inflammation = Sinusitis Combination of obstruction, infection, inflammation Constellation of symptoms: Facial pain, nasal obstruction, headache, thick nasal discharge, fatigue, fever Complicated sinusitis infection spreads outside sinus cavities

Patient Impact of Sinusitis Over 30 million Americans suffer from Sinusitis 1 : It is more prevalent than heart disease: 1 in 8 adults 1 18-22M office visits and 1.

6 Patient Impact of Sinusitis Over 30 million Americans suffer from Sinusitis 1 : It is more prevalent than heart disease: 1 in 8 adults M office visits and 1.2M Hospital visits/year 2 Direct annual cost $2.4 billion and increasing Added surgical costs: $1 billion Third most common diagnosis for which antibiotics are prescribed Quality of Life: Greater impact than CHF or chronic back pain 3 Associated with fatigue and depression 73 million days of restricted activity or lost work per year 2 However, remains underdiagnosed: 51% patients misdiagnose themselves with allergies 4 Only 36% are seen by their primary care physicians 5 1. National Health Interview Survey, National Ambulatory Medical Care Survey, 2005; National Hospital Ambulatory Medical Care Survey, Gliklich et al. Otolaryngol Head Neck Surg 1995;113: US Pharm. 2012; 37((7): Asthma and Allergy Foundation of America (AAFA) Kelton Research, April MPM Rev.A

7 Quality-of-Life Issues Fatigue Concentration Nuisance Sleep disturbance Emotional well being Social interactions Missing school/work Halitosis Decreased production Impaired studying Sniffing/snorting Blowing nose

Types of Sinusitis 1 Acute Rhinosinusitis (ARS): Symptoms of purulent nasal drainage accompanied by nasal obstruction and/or facial pain-pressure-fullness, <4 weeks duration.

2 Recurrent Acute Rhinosinusitis (RARS): 4 or more recurrent episodes of acute sinusitis per year, with clearing of symptoms between episodes.

9 Types of Sinusitis 1 Acute Rhinosinusitis (ARS): Symptoms of purulent nasal drainage accompanied by nasal obstruction and/or facial pain-pressure-fullness, <4 weeks duration. The majority of acute sinusitis episodes result from a virus and can often clear up after a period of watchful waiting. 2 Recurrent Acute Rhinosinusitis (RARS): 4 or more recurrent episodes of acute sinusitis per year, with clearing of symptoms between episodes. Chronic Rhinosinusitis (CRS): 2 or more sinusitis symptoms and evidence of swelling/inflammation that lasts > 12 weeks duration. 1. AAO-HNS Clinical Practice Guidelines 2015, Diagnostic Criteria for Rhinosinusitis 2. Infectious Diseases Society of America, news release, March 21, 2012

2 or More Symptoms: Facial pain / pressure Mucopurulent/discolored discharge Nasal congestion/obstruction, or Decreased sense of smell Healthy

10 Spotlight on Chronic Rhinosinusitis (CRS) Definition of CRS: symptomatic inflammation of the mucosa of the nose and paranasal sinuses > 12 weeks duration. 2 or More Symptoms: Facial pain / pressure Mucopurulent/discolored discharge Nasal congestion/obstruction, or Decreased sense of smell Healthy Open Sinuses Diseased Inflamed Sinuses And Evidence of Inflammation: Evidence of nasal polyps (via endoscopy) Purulent mucus or edema (via endoscopy) Inflammation shown on CT 1. AAO-HNS Clinical Practice Guidelines 2015, Diagnostic Criteria for Rhinosinusitis MPM Rev.A

Treatment Options Lifestyle Modifications Medical Management Sinus Surgery Environmental changes Smoking cessation Allergy testing & allergen avoidance Antibiotics Intranasal steroids Oral

11 Treatment Options Lifestyle Modifications Medical Management Sinus Surgery Environmental changes Smoking cessation Allergy testing & allergen avoidance Antibiotics Intranasal steroids Oral steroids Allergy medication Decongestants Saline rinses Immunotherapy Endoscopic sinus surgery (w/ steroideluting stent) Balloon dilation Polyp removal Turbinate reduction Septoplasty MPM Rev.A

12 Evaluation of Chronic Sinusitis Nasal Endoscopy telescope into the nose CT or MRI scanning Anatomic defects, tumors, fungi Allergy testing Inhalants, fungi, foods Sinus aspiration for cultures Bacterial Fungal

13 Nasal endoscopy

14 Acute sinusitis Middle Meatal Pus

15 Chronic Sinusitis

17 Medical Therapy

18 Treatment of Chronic Sinusitis Steam inhalation Nasal irrigation Nasal steroid spray Antihistamines (oral/nasal spray) Decongestants Antibiotics with active infections

19 What is Maximum Medical Therapy? Oral antibiotics of 2-4 weeks duration with chronic bacterial sinusitis Oral antibiotics with multiple 1-3 week courses for patients with recurrent acute bacterial sinusitis Topical and/or systemic steroids (at discretion of physician) Saline irrigations (optional) Topical and/or systemic decongestants (optional, if not contraindicated) Treatment of concomitant allergic rhinitis 1. AAO-HNS Clinical Practice Guidelines 2015, Diagnostic Criteria for Rhinosinusitis

20 Objectives of Treatment of Acute Bacteria Sinusitis Decrease time of recovery Prevent chronic recurrent disease Decrease exacerbations of asthma or other secondary diseases

21 Nasal Irrigation Commercial buffered sprays Bulb syringe 1/4 tsp of salt to 7 oz water Waterpik with lavage tip 1 tsp salt to reservoir Disposable enema bucket 2 tsp salt, 1 tsp soda per quart of water

22 Nasal Irrigation Washes away irritants Moistens the dry nose Waterpik with nasal irrigator Ceramic irrigators Enema bucket with normal saline and soda Hose-in-the-nose -- $2.50

23 Nasal Irrigation With enema bucket/hose. Add 2 teaspoons of salt and 1 tsp of baking soda to a quart of warm water Over tub, sink, or in shower lean over, head tilted slightly downward and to side place hose in upper nostril (fluid may return from either nostril or through mouth) run in 1/2 solution. Turn head to opposite side and repeat process. Use once, twice daily or as often as needed

24 Decongestants Topical nasal sprays (limit use to 3-7 days) Phenylephrine Oxymetazoline Topical nasal spray (unlimited daily use) Ipatropium Flonase, Nasonex, Nasacort, Rhinocort, Veramyst, Omnaris Astepro, Astelin, Patanase Oral Pseudoephedrine mg Phenylephrine 2-4 times/day Steroids

25 Mohammed et al. Otolaryngol Clin N Am. 38 (2005)

26 Mohammed et al. Otolaryngol Clin N Am. 38 (2005)

27 Mohammed et al. Otolaryngol Clin N Am. 38 (2005)

28 Mohammed et al. Otolaryngol Clin N Am. 38 (2005)

29 Surgical Therapy

Endoscopic Sinus Surgery Over 500,000 patients undergo sinus surgery each year in the US Surgery is performed through minimally invasive endoscopic access of the nasal passages No external incisions

30 Endoscopic Sinus Surgery Over 500,000 patients undergo sinus surgery each year in the US Surgery is performed through minimally invasive endoscopic access of the nasal passages No external incisions or scars No Gauze packing- rarely used due to other advances Healthy sinuses with normal drainage pathway Chronic sinus disease blocks the drainage pathway Sinus surgery restores the natural drainage pathway

Indications for & Role of Surgical Treatment of Rhinosinusitis 1 Potential Indications: Failure to adequately control symptoms of CRS despite maximal medical therapy where there is objective evidence

31 Indications for & Role of Surgical Treatment of Rhinosinusitis 1 Potential Indications: Failure to adequately control symptoms of CRS despite maximal medical therapy where there is objective evidence of disease. Sinonasal polyposis with nasal airway obstruction or suboptimal asthma control Allergic fungal rhinosinusitis Recurrent acute rhinosinusitis (RARS) Role of Surgery: Ventilates (drains) sinus cavities Removes inflamed/diseased tissue and polyps Enlarges sinus pathways to provide optimal access for topical therapies 1. Adapted from American Academy of Otolaryngology- HNSF, Clinical Indicators: Endoscopic surgery, Adult Other potential indicators include: Unilateral paranasal sinus opacification, consistent MPM with Rev.A CRS, fungus

Evolution of Sinus Surgery Technology 1 Treating

anatomic & inflammatory factors, less tissue removal

Microdebrider Image Guidance Balloon Dilation Steroid

in the US over 25 years ago Trend from treating

invasive and more targeted treatments. 1.

32 Evolution of Sinus Surgery Technology 1 Treating anatomic factors only, more tissue removal Treating anatomic & inflammatory factors, less tissue removal Endoscope ENT Suction, Irrigation & Drill Microdebrider Image Guidance Balloon Dilation Steroid Eluting Stent Endoscopic sinus surgery was introduced in the US over 25 years ago Trend from treating anatomic factors only to also addressing underlying inflammatory factors. Advanced technologies have paved the way for less invasive and more targeted treatments. 1. Govindaraj S, Adappa ND, Kennedy DW. J Laryngol Otol Endoscopic Sinus Surgery: Evolution and Technical Innovations.

33 MPM Rev.A Ongoing CRS Patient Management: A Chronic Puzzle Requiring Many Inputs Lifestyle Modifications Endoscopic Sinus Surgery Asthma Control Medical Management In-Office Procedures Allergy Treatments We look forward to being an ongoing partner with you in the diagnosis and treatment of your chronic sinusitis patients.

34 Why Surgical Treatment? Polyps Failure of medical therapy (allergy) Complicated sinusitis Suspect tumor Goal: enhance sinus anatomy to improve aeration and drainage and thus prevent sinusitis = open and drain the sinuses

35 F.E.S.S. Functional Endoscopic Sinus Surgery 1980 s - Messerklinger Improved equipment/scopes allowed for surgery through the nostrils Enhance drainage of sinuses through the naturallyoccurring windows

36 The Good Old Days Caldwell-Luc Puncture the front cheek Naso-antral windows External approaches Extensive nasal packing 10 feet of packing! Hospitalization Lengthy recovery

38 Preoperative Evaluation Medical / cardiac clearance for general anesthesia Hold anticoagulation medications Preoperative corticosteroids Outpatient surgery 1.5 to 2.5 hours case duration Prescriptions

39 Stereotactic Image Guidance Wear headband while in surgery Like a GPS system for sinus surgery Allows for safer surgery, more complete dissection, faster

40 Stereotactic Image Guidance Source: J Anon. Laryngoscope 1998;108:949.

41 What is the Ostiomeatal Complex Ostiomeatal complex (OMC) is that area under the middle meatus (air space) which drains the ethmoid, frontal and maxillary sinuses. So the OMC is the functional space where the sinuses drains, and therefore our surgical target.

42 Surgical technique

44 Surgical Goals Restore/augment sinus drainage passageways Clear polyps/inspissated mucous or infection/fungal balls Preserve mucosa No more sinus scraping. Avoid complications Minimal packing

45 Balloon Sinuplasty New minimally-invasive way of creating a wider window into certain sinuses New technique with less bleeding, quicker surgery time, decreased healing time Safe and effective 0% Complication Rate

Advanced Technologies: Image Guidance/Surgical Navigation Surgical GPS : can follow the location of surgical instruments on a computer monitor in real time, based on a pre-op image data

46 Advanced Technologies: Image Guidance/Surgical Navigation Surgical GPS : can follow the location of surgical instruments on a computer monitor in real time, based on a pre-op image data set. Helps map out difficult anatomy at critical points in the surgery. Brown, S et al Medscape accessed August 2015: MPM Rev.A

47 Advanced Technologies: Balloon Treatment Procedure to open obstructed sinuses using balloon dilation An option to open peripheral sinuses like frontal, maxillary and sphenoid Can be performed under local anesthesia typically with minimal recovery period MPM Rev.A

48 Relieva Balloon Sinuplasty devices Designed for customized access Sinus Illumination System Sinus Guide Catheter Engineered for sinus dilation Sinus Balloon Catheter Developed for controlled inflation Sinus Balloon Inflation Device

49 1. Balloon is inserted in sinus over a wire 2. Balloon is inflated to dilate the sinus opening 3. Irrigation/ flushing of sinus cavity 4. Device is removed leaving the opening dilated

frontal, anterior ethmoid, and maxillary sinuses

51 The Middle Meatus Anatomic space between middle and inferior turbinates Site of drainage for frontal, anterior ethmoid, and maxillary sinuses Sinus surgery failure: lateralized middle turbinate

Control POST-OPERATIVE INTERVENTION 35% p=0.0008 POLYPOSIS 46% p<0.0001 NEED FOR ORAL STEROIDS 40% p=0.

52 Advanced Technologies: Steroid-Eluting, Dissolvable Sinus Stent (PROPEL ) 1. Delivery into ethmoid sinus 2. Spring-like action to maintain sinus opening 3. Localized delivery of Mometasone Furoate 4. Dissolves in place/ bioabsorbable PROPEL vs. Control POST-OPERATIVE INTERVENTION 35% p= POLYPOSIS 46% p< NEED FOR ORAL STEROIDS 40% p= SCARRING (ADHESIONS ) 70% p= MT LATERALIZATION 75% p= Meta-analysis: Han JK, Marple BF, Smith TL et al. Int Forum Allergy Rhinol, Vol. 2, No. 4, July/August 2012 MPM Rev.A

53 PROPEL Sinus Stent Animation* *requires internet connection to run in full presentation mode.

54 Postoperative Care In-office debridements to clear clot, fibrinous debris, ensure sinus patency Nasal saline irrigations Resume medical therapy for rhinitis control

55 Postoperative Care In-office debridements to clear clot, fibrinous debris, ensure sinus patency Nasal saline irrigations Resume medical therapy for rhinitis control

6340 N Campbell Ave, Ste 256 Tucson, AZ 85718 1521 E Tangerine

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Sinusitis: Medical and Surgical Management. R. Jonathan Lara, DO, FAOCO. Sonoran Ear Nose & Throat

Sinusitis: Medical and Surgical Management R. Jonathan Lara, DO, FAOCO Sonoran Ear Nose & Throat 27 th Annual Southwestern Conference on Medicine April 26, 2018 What are sinuses? Air filled cavities of